AAA Physical Therapy Intake Form
8975 Guilford Rd Ste 170 Columbia, MD 21046
Full Name
First Name
Last Name
DOB
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Month
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Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Preferred Pronoun
Cell Phone
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Area Code
Phone Number
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Primary Physician
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Back
Next
FITNESS Goals:
Lose Weight
Body Toning
Other
STRESS Level :
1
2
3
4
5
Low
Hign
1 is Low, 5 is Hign
What’s the main cause?
NUTRITION:
What is your level of nutrition knowledge?
None
A little
Medium
A Lot
Do you want to know more about nutrition?
Yes
No
SUPPORT STRUCTURE:
Who do you have nearby that is close to you?
Family
Friend(s)
None
Other
Name something that is really important to you (or really enjoy doing)?
How did you hear about us?
Doctor
Lawyer
Friend/Family
Google
Marketing Event
Yelp
Returning Patient
Other
Best way to contact you?
Email
Phone Call
Text Message
Reminders
Back
Next
IMPORTANT RULES & POLICIES
Please initial each policy.
*
1. Late Policy: If I’m late more than 10-minutes to my appointment, I may be rescheduled or asked to wait for next available open time slot.
2. Co-pays, coinsurances, and/or deductibles are due prior to treatment starts.
3. Not showing for an appointment without notice may result in a $60 fee added to my account.
4. Cell phones must be shut OFF or silent. There is no recording audio/visual allowed in the practice.
5. Children requiring supervision are NOT allowed to attend sessions with you without prior authorization.
6. If you are experiencing any financial hardship, please notify us immediately so we can create a feasible payment program.
7. I declare under penalty of perjury in the State of Maryland that the insurance information is true and correct, this is not a third party (someone else) insurance, and that I am a direct beneficiary (self, spouse, child) of the policy holder.
8. We are here to help you make informed decisions regarding your payment options to cover the COC (Cost of Care), however, you are responsible for verifying your benefits with your health insurance if you wish to use that to cover your payments for services rendered. We offer a complimentary benefits verification with you, ask our Front Desk about it. You are also responsible for changes of your insurance, work compensation information, or auto / vehicular accident case with / without lawyer.
9. You may receive through text / email about blogs / podcasts / events and any other communication from AAA PT.
10. If for any reason you are NOT satisfied with the care received, please contact our administrator at 443-979-7171 or admin@aaaphysicaltherapy.com.
11. I was informed that billing information such as cost of care verification, statements and account balances are sent through a safe online portal and an email will be sent to notify for the link to access and make payments.
Date
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Month
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Day
Year
Date
Signature
If patient is a MINOR, parent/guardian’s name:
First Name
Last Name
Parent/guardian signature:
Submit
p. 443.979.7171
AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046
f. 667.200.5908
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